Healthcare Provider Details

I. General information

NPI: 1790263267
Provider Name (Legal Business Name): ASHLEY OLMEDO MENDOZA BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 E COOLEY DR
COLTON CA
92324-3905
US

IV. Provider business mailing address

1330 E COOLEY DR
COLTON CA
92324-3905
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-3712
  • Fax:
Mailing address:
  • Phone: 909-580-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number116328
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: